How to do a cardiovascular examination - Full Guide and Video

Cardiovascular Examination

Doctor Khalid

The cardiovascular examination (CVS) is the examination of a patient's heart and circulatory system. The CVS exam does not simply focus on the chest but is also a systemic clinical examination of the patient. It is also one of the core aspects of any OSCE exam. In the real world, any patient that is admitted into the hospital needs to have a cardiovascular exam completed. Often the patient's with chest pain, shortness of breath or palpitations will need specific focus on their cardiovascular system due to the nature of their presenting complaint.
Guess which one is my brother! 

Introduction

  1. Wash hands

Wash your hands using the Ayliffe technique

2. Introduce yourself

Introduce yourself and give your name and grade

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Hi, my name is John Smith and I am a 4th-year medical student”

3. Check patient details

Clarify patient's identity by confirming name and asking for their DOB

4. Describe the examination

Explain what examination you are performing and what it involves

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“I have been asked to perform a Cardiovascular examination on you today. This involves having a look at your hands and face, having a feel of your chest and a listen to your heart”

5. Gain verbal consent

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“Would this be ok with you?”

6. Offer a chaperone

Ask if they would like a chaperon


Peripheral Examination

  1. Positioning patient at 45 deg

Initially lie the patient at 45 degrees and expose them from waist up

2. End of bed inspection

Inspect the patient from the end of the bed and look for the following:

  • Patient - Note any tachypnoea, cachexia, oedema.
  • Adjuncts - eg. any supplemental O2 (%), IV lines, infusions, catheter
  • Paraphernalia - eg. GTN spray, cigarettes, walking aid

3. Inspect the hands

Inspect the hands and check for stigmata of chronic GI disease

Skin

  • Tar staining (smoker)
  • Janeway lesions - micro-abscess, painless (pathognomonic of subacute infective endocarditis)
  • Osler nodes - inflammatory complex, painful (10-25% of IE)
  • Xanthomata - cholesterol deposits in tendons of hand and elbows (hypercholesterolaemia)
  • Scar - Radial scar from angiography
  • Temperature
  • Cold hands - Poor cardiac output, Raynauds, PVD

Nails

  • Clubbing (Cyanotic heart disease - Fallot’s tetralogy,transposition of great arteries, Eisenmenger's, chronic endocarditis)
  • Splinter haemorrhage (Subacute bacterial endocarditis)
  • Koilonychia (iron deficiency)

4. Check pulse and respiratory rate

Check the patient's pulse and resp rate. Time for 15 seconds and multiply by 4.

  • Irregular (AF, ectopics, respiratory sinus arrhythmia)
  • Pulsus paradoxus  - decrease in amplitude of pulse/BP during inspiration (cardiac tamponade, constrictive pericarditis)
  • Pulsus alternans - alternating weak and strong beats (LV dysfunction)
  • Collapsing pulse - tapping (Aortic regurgitation)

Delay

  • Radio-radial - coarctation aorta (pre left subclavian), dissection
  • Radio-femoral - coarctation aorta (post left subclavian)

5. Inspect the face and neck

Next, inspect their eyes, mouth for the following.

Examination of eye for cardiovascular examination - what to look for

Eyes

  • Xantholesma - yellow deposits around skin of eyes (hypercholesterolaemia)
  • Corneal arcus - white, grey, blue ring around edge of  cornea (hypercholesterolaemia, unilateral ?decreased blood flow to eye)
  • Pale conjunctiva (anaemia)

Skin

  • Malor flush - flushing of cheeks (mitral regurgitation)

Mouth

  • Cyanosis
  • Glositis - large tongue (iron deficiency)
  • Angular cheilitis - cuts to edge of lips (iron deficiency)

6. Inspect the neck for the JVP

There are seven features of a JVP that distinguish it from other vessels.

  • Complex waveform
  • Non-palpable
  • Collapsible
  • Predominantly down going
  • Changes in inspiration (normal to go down)
  • Changes with positioning
  • Hepatojugular reflex
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Kusmauls sign - JVP rises on inspiration (cardiac tamponade, constrictive pericarditis)
Raised (Sign of fluid overload)
Canon waves - large a wave (complete heart block)

Chest examination

1. General Inspection

Inspect the chest  again more closely and look for the following:

Scar

  • Central sternotomy (CABG, valve replacement, cardiac surgery)
  • infraclavicular (PPM, defibrillator, reveal device)

PPM boxes

2. Palpation of the chest

Palpate the chest wall, feeling for the following.

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Remember to warn the patient that you will be feeling under the left breast to feel for the apex beat

Heave - hypertrophy
Thrill - palpable murmur
Apex beat - Normally 5th IC space mid-clavicular line

3. Listen to the heart sounds

Listen to the following four areas of the chest for the heart sounds.

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Mitral region (apex beat / 5th IC space)

Murmur

  • Stenosis (Mid-diastolic)
  • Regurgitation (pan-systolic)

Manoeuvres

  • Lie on the left side
  • Expiration - enhances left-sided heart sounds
  • Bell of stethoscope - high pitched MS murmur
  • Axilla radiation - mitral regurgitation
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Tricuspid region (4th IC space left sternal edge)

Murmur

  • Stenosis (Mid diastolic murmur)
  • Regurgitation (pan-systolic)

Manoeuvres

  • Inspiration - enhances murmur
  • Liver - pulsates with heartbeat and murmur can be heard in severe TR
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Pulmonary region (2nd IC space left sternal edge)

Murmur

  • Stenosis (early systolic)
  • Regurgitation (early diastolic)

Manoeuvres

  • Inspiration - enhances murmur
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Aortic region (2nd IC space right sternal edge)

Murmur

  • Stenosis (ejection systolic, crescendo-decrescendo)
  • Regurgitation (early diastolic)

Manoeuvres

  • Expiration - enhances murmur
  • Listen to carotid - aortic stenosis
  • Sit forward (listen to 4th IC space left sternal edge) - Aortic regurgitation

High Key Marble Body.

4. Examine the back

Inspect the back and check for the following.

  • Sacral oedema (fluid overload and heart failure)
  • Listen to the base of lungs (fluid overload and heart failure)

5. Conduct a brief vascular exam

  • Aorta
  • Palpate - Pulsatile/expansile (aneurysm)
  • Listen
  • Aortic bruis
  • Renal bruis (renal artery stenosis)
  • Femoral (inguinal line)
  • Palpate
  • Check for femoral-femoral delay
  • Popliteal
  • Posterior tibialis
  • Dorsalis pedis

6. Check for peripheral oedema

Check for peripheral oedema. Note if it is pitting and to what level it extends.


End of examination

  1. Thank patient

Let the patient know you have finished examining them and thank them for their time. Be courteous and offer them help to get redressed.

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“That’s the end of the exam. Thank you for your time. Would you like any help getting dressed?”

2. State other exams for completion

Turn to the examiner and state what else you would do to complete the exam.

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“To complete the examination I would check the patient's BP. I would also perform fundoscopy of the eyes.”

3. State what tests you would perform

Explain to the examiner what tests and investigations you would perform

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ECG
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Urine dip - Proteinuria
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FBC - anaemia/infection
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U&E - renal function (if on ACEi/diuretic)
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LFT - ALP if severe overload, dysfunction if on amiodarone
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Lipid profile - hypercholesteralaemia
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Blood cultures - 3x from different place and time (IE)
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BNP - if heart failure
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CXR
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Cardiomegaly - HTN disease, HF, cardiomyopathy
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Fluid overload - increased vascular marking, effusions, fluid in fissure, curly B lines

If you have found this useful please share it - with your fellow students and friends! Thank you.

Doctor Khalid